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	<meta name="Description" content="專人回覆 - 有線電視/數位節目/光纖上網業務服務連繫" />
	<title>專人回覆 - 有線電視/數位節目/光纖上網業務服務連繫</title>
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<body style=" background: #c4ced1;">
<form name="uniContactForm" id="uniContactForm" method="post" class="uniForm">
	<input type=hidden name="表單" value="專人回覆">
	<fieldset>
	<h3>請填寫您的聯絡資料，我將會以最快的速度回電。</h3>

	<div class="ctrlHolder">
		<label for=""><em>*</em> 您的姓名</label>
		<input name="姓名" id="姓名" data-default-value="姓名" size="35" maxlength="10" type="text" class="textInput required"/>
		<p class="formHint">您的稱呼</p>
	</div>
	
	<div class="ctrlHolder">
		<label for=""><em>*</em> 聯絡電話</label>
		<input name="電話" id="電話" data-default-value="電話" size="35" type="text" class="textInput required"/>
		<p class="formHint">您的行動電話或市話號碼<br>市話請加區碼</p>
	</div>

	<div class="ctrlHolder">
		<label for="">  所在區域</label>
		<select size=1 name=區域>
		<script language='javascript'>document.write(getParameterZone(getParameterByName('key')));</script>
		</select>
	</div>

	<div class="ctrlHolder">
		<label for="">  洽詢項目</label>
		<select name="項目" tabindex="6">
			<option value="有線電視">有線電視</option>
			<option value="有線電視+光纖上網">有線電視+光纖上網</option>
			<option value="有線電視+數位電視">有線電視+數位電視</option>
			<option value="數位電視(收視戶)">加裝數位電視(現有收視戶)</option>
			<option value="光纖上網(收視戶)">加裝光纖上網(現有收視戶)</option>
			<option value="光纖上網(BBonly)">單裝光纖上網(不安裝有線電視)</option>
		</select>
	</div>

	<div class="ctrlHolder">
		<label for="">  備註</label>
		<textarea name="備註" cols=50 rows=2></textarea>
	</div>
		
	<div class="buttonHolder">
		<button type="submit" class="primaryAction" id="SubmitButton">送出資料</button>
	</div>
	<div class="bottom"></div>
</form>
</body>
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		prevent_submit : true
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